Efficacy evaluation of endolift laser for treatment of nasolabial folds and marionette lines

Abstract Background The nasolabial folds are the most marked sign of aging. Endolift laser was used for the treatment of nasolabial folds and marionette lines (one of the facial danger zones). Methods Ten female subjects were engaged in this study. Patients underwent Endolift laser for nasolabial folds and marionette lines treatment. The efficacy of the Endolift technique on the nasolabial folds and marionette lines was evaluated by biometric assessment with Cutometer, Visioface, and the Skin Ultrasound Imaging system. Also, patient's satisfaction and blinded dermatologists’ assessment were assessed. Results The Visoface results displayed that the Endolift laser treatment significantly declined the depth and area of the nasolabial wrinkles. The skin ultrasonography results reported that the epidermis and dermis density and thickness were significantly increased. Also, the cutometer outcomes showed that the Endolift laser treatment can increase skin elasticity. The results showed that a large number of patients were very satisfied with the technique. Conclusion In conclusion, Endolift laser has an effective technique for decreasing the nasolabial folds, marionette lines, and improve the appearance of the face without any sever side effect. This technique does not need general anesthesia and recovery time.

changes are due to morphologic changes of the muscle function and skin sagging. 6Nasolabial folds look like wrinkles, because both are shaped by folding of the dermis.Several aesthetic techniques are used for nasolabial rejuvenation like microneedle, 7,8 radiofrequency, 9 and filler injection [10][11][12][13] but each method has its own risks.Ablative laser resurfacing by erbium: YAG (Er:YAG) laser and carbon dioxide laser is an effective method for rejuvenation of the skin but has probable side effects like, infection, prolonged erythema, and scarring. 146][17][18] Therefore, this study aimed to investigate the effect of Endolift laser therapy as a novel technique on nasolabial fold and marionette lines (one of the facial danger zones).

Subjects selection
In total, 10 healthy female and male patients suffering nasolabial fold and marionette lines were joined in this study.The age variety was from 25 to 58.Written informed consent forms were gained from all individuals for the investigations.Patients with coagulopathy, immunocompromised status, active infection, cancer, and autoimmune disease were excluded, pregnant patients were also excluded.

Study design and laser technique
Endolift™ (LASEMAR1500TM machine, Eufoton s.r.l.) was used in this study.A sterile set was prepared for each patient.A sterile set includes betadine galipot, injectable serum galipot, syringe containing injectable lidocaine for anesthesia, sterile gauze, sterile gloves, and sterile fibers for Endolift.The intervention area (perioral area) was cleaned using betadine and the target area was cleaned of betadine using injected serum.Injectable lidocaine (2% lidocaine) was used in the nasolabial area that was the site of Endolift fiber insertion in to the skin and the fiber movement area was numbed.After local anesthesia, the sterile fiber was inserted into the skin and the fiber was moved superficially in fanning motions to avoid temperature rise in the intervention area, the laser diode was induced at the same time (Figure 1).In this treatment method, the 300 µ fiber was used.To perform the procedure in this area, energy and time were reduced because this area is one of the facial danger zones.The intensity and the power of the device include; Pulse: 3, T on -T off: 25-75, shot number: 200-250 shots on each side of the face, total shots for the whole of the nasolabial area: 400-500.The intensity and power of the device were the same in all area of intervention and the patients received the treatment one time.
The necessary care after treatment was explain to the patients.For the patients with the history of herpes, acyclovir tablets were prescribe and the antibiotic was prescribed to prevent possible infections after the procedure of 5 days.The possible side effects like infection, ery- thema, and swelling were noted and managed after treatment.This treatment method does not have recovery period or down time.The patients were followed for 3 months after the procedure and the they underwent biometry and skin analysis.

Biometric evaluation
Before and after 3 months of the treatment, the patients biometric parameters were appraised by Cutometer, the Skin Ultrasound Imaging system (TPM, Germany; DUB Skin Scanner; 75 MHZ probe) and Visioface (Germany).The skin elasticity was measured by Cutometer with analyze of three factors R2, R5, and R7.The skin aging and elasticity were evaluated by R2 and R7 and it showed that they are the important parameters of Cutometer.R2 reported skin viscoelasticity, containing viscous deformation and R7 reported the biological elasticity, R5 reported net elasticity.The changes in the volume, depth, and area of the skin wrinkle were appraised by Visoface (multi-probe adapter).The skin ultrasound imaging system is related to the dermis and epidermis diameter and density.The increase in the dermis density is associated with the increase in dermis collagen.The erythema was assessed by Mexameter MX 18 probe (data not shown).

Objective and subjective methods
Before and after 3 months, the treatment digital photographs were taken with identical camera (Nikon, 10.2 million pixels, Tokyo, Japan) settings.The clinical effects of the Endolift methods on the nasolabial fold and marionette lines were evaluated by objective and subjective methods.The objective method comprised three blinded dermatologist evaluations of photographs before and after laser treatment.
The subjective method included patient's satisfaction.The outcomes were classified as follow: no satisfaction, slightly satisfied, moderately satisfied, and well satisfied.

TA B L E 1
Comparing biometric characteristics of the skin before and 3 months after treatment.

Statistical analysis
Statistical analysis was performed by SPSS 15.0 statistical software (SPSS) in this study.A P value of less than 0.05 was noted statistically significant.

Biometric parameters changes results
The biometric measurement results of all patients are shown in between the erythema before and after procedure.The patients were monitored for 3 months and no side effects were informed during the study.

Patients and physicians' assessment results
Regarding patients' satisfaction, a significant number of patients were well satisfied (N = 6) after treatment (Table 2) (p <0.05).The physician reported a significant satisfaction after Endolift laser treatment.The results are shown in Table 3 (p < 0.05).
According to these previous studies, Endolift laser can decrease the skin laxity and can tight the skin and also can decrease the facial wrinkles.To our knowledge, this is the first report of Endolift laser that show F I G U R E 5 Skin analysis with ultrasonography for case B.
it is a safe and effective method to decrease the nasolabial fold and marionette lines.and improve the appearance of the face.This procedure does not require general anesthesia and recovery time.Various treatment methods have been used for nasolabial folds' improvement comprising, botulinum toxin injection, dermal fillers, high intensity focal ultrasound (HIFU), fractional CO2 laser, and thread lifting. 29metimes, to gain a better cosmetic results, a combination of some treatment modalities is used.Laser skin resurfacing has still been considered the gold standard for skin rejuvenation.Howyda et al. reported that intraoral Er:YAG laser is effective treatment for nasolabial folds wrinkle. 30There are some studies studying the efficacy of intraoral fractional Er: YAG laser in improvement of nasolabial folds. 31,32In this study we used Endolift laser for nasolabial fold treatment.The Endolift laser technique is non-invasive method with don't need anesthesia, recovery time, and have no adverse effects, also it will tolerate with the patients.Endolift laser is leading to shrinkage and contraction of tissue which resulting in new collagen formation and collagen remodeling.The collagen is responsible for improvement of skin thickness, elasticity, and fill in wrinkles [33][34][35][36]

CONCLUSION
Endolift laser is an effective technique for decrease of the nasolabial folds and marionette lines (one of the facial danger zones) and improvement of the appearance of the face without any sever side effect.This technique does not need general anesthesia and recovery time.

Study limitation
Further studies are recommended to assess more numbers of patients and longer follow-up periods.

F I G U R E 4
nation to achieve youthful looking skin.Nasolabial folds are one of the signs of aging that depends on several factors such as smoking, aging, and sun exposure.Nasolabial folds look like wrinkles, because F I G U R E 2 Visioface wrinkle analysis for case A: decrease in volume, area and depth of the nasolabial folds and marionette lines after treatment.F I G U R E 3Visioface wrinkle analysis for case B: decrease in volume, area and depth of the nasolabial folds and marionette lines after treatment.Skin analysis with ultrasonography for case A.both are shaped by folding of the dermis.Nasolabial folds and marionette lines are the most visible signs of aging in lower face likewise, they are very common at the age of under 30.19Most of the patients would like nasolabial fold and marionette lines to be less visible.In this study, Endolift laser technique was performed for the nasolabial fold and marionette lines treatment.In this research study, the results were evaluated by biometric changed and patients satisfaction.Also, three blind dermatologist assessed the results.Our Visioface results displayed that the Endolift laser significantly decrease the area and depth of nasolabial fold and marionette lines.The skin ultrasonog-raphy results reported that the epidermis and dermis density and thickness were significantly increased.Also the cutometer outcomes displayed that the Endolift laser treatment can increase skin elasticity.In some previous published study, the effect of Endolift laser for treatment of forehead wrinkles, acne scars, upper eyelid, and eyebrow ptosis, arm and under abdomen fat, lower eyebag, skin laxity, jowl fat,

Table 1
results and the cutometer outcomes displayed that the Endolift laser treatment can increase skin elasticity (p <0.05) (Table1).The percentages of change in R2, R5, and R7 were 25.32 ± 8.14, 26.13 ± 10.08, and 25.41 ± 6.26, respectively.The patients showed mild edema and erythema, after the treatment which was completely resolved after 1 or 2 days.The mexameter data showed no significant difference TA B L E 2 Patient satisfaction for nasolabial folds and marionette lines treatment 3 months after Endolift laser treatment.The P <0.05 was considered as statistically significant.
Physician assessment after treatment.The data was shown as mean ± SD.
. So this technique can increase tissue tightness and improvement of nasolabial fold wrinkles.Endolift laser TA B L E 3